Facet Joint Pain

Recently Spine-Health.com featured the blog post below by Dr. Stephen Hochschuler, co-founder and orthopedic spine surgeon at Texas Back Institute.

Stephen_Hochschuler_MD

Facet Joint Pain after Spine Surgery

The facet joints are two small joints in the back of the spine, on the left and right sides, at each level. These joints work with the discs to provide support and motion to the spine.

There are several ways in which these joints can produce pain:

  • Nerves in the joints can be compressed and/or irritated by inflammatory agents
  • Facet joints can degenerate, become arthritic, and produce pain by forming osteophytes (bone spurs) which compress nerves passing into the legs.

As with many joints, degenerative changes can occur in the facets, which can become painful. Degeneration is likely to occur in the spine as a part of the aging process, regardless if surgery has been performed or not. However, some types of spine surgery may alter load or movement patterns of the spine, which in turn can affect the facet joints.

Causes of Post-operative Facet Joint Pain

Facet joints may be related to pain after spine surgery in several ways:

  • These joints may continue to degenerate after a surgical procedure to treat a herniated disc or compressed nerve roots at the same spinal level
  • Surgery may change the loading or movement patterns of these joints, leading to degeneration and pain.

Following a spine fusion at one spinal level, motion of the level(s) next to it may be altered to compensate for changes the fusion caused. This change in motion pattern may cause facets at the adjacent segment(s) to degenerate and become painful.

Facet joint pain is difficult to identify without injections into these joints. In back pain patients, pain may arise from more than one source within the spine. While surgery may address one problem, existing facet joint pain may not have been recognized prior to the spine surgery, and therefore not addressed.

Treatment Options for Facet Joint Pain

Treatment of facet joint pain may include one or a combination of the following:

  • Physical therapy
  • Medication
  • Chiropractic care/manual manipulation

If these treatments do not provide relief, then more invasive procedures are an option, including:

Treatment Considerations

The most important aspect of pre-operative planning for facet joint pain is the diagnosis. As with real estate investments, where the focus is on “Location, Location, Location,” for spine surgery the name of the game is “Diagnosis, Diagnosis, Diagnosis.”

It is therefore stressed that before any spinal surgical intervention is considered, a thorough diagnostic work up is needed to determine any and ALL causes of the back pain one is addressing.

This is part of the reason that a preoperative discussion and a patient education program is necessary. This process will afford the patient a full understanding as to what is known and unknown in each individual case and what expectations can be set in accordance with all treatment variables.

The EMG Study

As featured on Spine-Health.com. Dr. Patel is a physiatrist and treats patients suffering from neck and back pain.

Contributed by Nayan Patel, MD

For the spine patient with Failed Back Surgery Syndrome, the electrodiagnostic study helps the physician assess for nerve damage coming from the cervical or lumbar spine, as well as evaluate for other nerve-related problems in an extremity (such as peripheral neuropathy).

Because symptoms from a patient withFailed Back Surgery Syndrome can be complicated, additional electrodiagnostic tests can help the physician with accurate diagnosis of the origin(s) of the patient’s pain.

An electrodiagnostic study, commonly called an EMG, is used to evaluate muscle and nerve function of a person who has extremity or facial pain, numbness and/or weakness. The study can be used to assess for cervical or lumbar radiculopathy (nerve damage from spine disease), any co-existing peripheral neuropathy (nerve damage from diseases like diabetes), myopathy (muscle disease) or focal neuropathy.

The test also helps localize the location of spinal nerve damage as well as distinguish if the damage is new or old, and progressive or stable.

There are two parts to an electrodiagnostic evaluation: nerve conduction study (NCS) and electromyography (EMG).

Nerve Conduction Study (NCS)
The NCS is done with a stimulator that generates a mild shock that travels down the nerve; the signal generated is picked up by an electrode placed at a specific distance. The data obtained give the testing physician information regarding the speed and strength of the nerve signal. The NCS picks up signals from two types of nerves: the sensory nerve, which provides sensation signals from the skin, and the motor nerve, which provides power signals to the muscles.

Electromyography (EMG)
The EMG study is done with a sterile, small gauge amplifier needle inserted into the muscles of an affected extremity. Each muscle is powered by specific sets of spinal nerves: for example, the bicep is powered by the C5 and C6 spinal nerves. If an abnormality is seen in the activity of a muscle or group of muscles, the physician can determine which spinal nerve is likely involved. The study can also help assess the age, extent, and possible progression of damage.

The complete EMG test takes 30 minutes to one hour. Although uncomfortable for some patients, the test is well tolerated and there is no persistent discomfort. The ordering physician may use the study in conjunction with other diagnostic studies, such as an MRI or CT scan, especially if the problem is thought to originate in the spine.

Since a patient who has failed spine surgery syndrome can have complicated symptoms, the evaluating surgeon can have difficulty telling if a person’s ongoing pain is coming from a spinal nerve. The EMG study will help evaluate active versus inactive spinal nerve damage as well as localize the spinal level of nerve damage. It will also help assess for any coexisting peripheral nerve damage.

Presurgical Psychological Screening, Understanding Patients and Improving Outcomes

Along with Dr. David Sarwer, Dr. Block has edited a fascinating new book – Presurgical Psychological Screening, Understanding Patients and Improving Outcomes – on pre-operative psychological screening. This book promises to set the standards for this critical stage in the recovery of surgical patients.

The success of many surgical procedures depends not only on the skill of the surgeon and the use of state-of-the-art technology, but also on the actions and characteristics of the patient. Patients’ emotional and psychosocial concerns, health-related behaviors, outcome expectations, and compliance with treatment regimen can all strongly influence the ultimate effectiveness of surgery.

Block

Thus, mental health professionals are increasingly called upon to perform pre-surgical psychological screening (PPS) to ensure that patients are given the treatments most likely to be effective, while reducing the chances of worsening their conditions.

This book presents PPS procedures for a wide range of surgery types, such as spinal surgery, organ transplantation, bariatric surgery, and plastic surgery. Drawing on both research and clinical experience, the authors explain how to conduct PPS, communicate results to patients and surgeons, and identify possible pre- or post-surgery interventions to mitigate risk factors and maximize the likelihood of surgical success.

Congratulations, Dr. Block!

Failed Back Surgery Syndrome

The post below was featured on Spine-Health.com and was contributed by Dr. Stephen Hochschuler, co-founder and orthopedic spine surgeon at Texas Back Institute.

Failed Back Surgery Syndrome (FBSS) refers to chronic back or neck pain, with or without extremity pain, which occurs if spine surgery does not achieve the desired result. Contributing factors include recurrent disc herniation, compressed nerves, altered joint mobility, scar tissue, muscle deconditioning and degeneration of facet or sacroiliac joints.

The problem of failed spine surgery has long been a perplexing and intriguing problem my colleagues and I have tried to accurately analyze and pro-actively prevent. My goal as a spine surgeon is to help treat patients with pain stemming from their spine. Many times I am able to treat patients with nonsurgical treatment options, such as physical therapy or medication, and they do very well. In some instances though, this treatment plan does not provide patients with the pain relief needed so we have to pursue more aggressive treatment options including surgery.

I always consider surgery to be a last option approach to spine care and therefore am very careful to make sure my patients are in the best position to have a successful surgery, in turn minimizing the chances of FBSS. Through experience I know there are several factors that have shown to contribute to failed back surgery syndrome, and therefore I follow the protocol below to make sure my patients are set up for their best outcomes:

  1. Before the surgery:
    • Always treat patients conservatively (non-operatively) first
    • Make sure the patient is correctly diagnosed – meaning that the cause of the patient’s pain has been accurately identified
    • Provide a thorough pre-operative evaluation
    • Make sure the surgery is the right one for the patient
    • Appropriately educate and set expectations for the patient, including pre-operative psychological evaluations.
  2. During the surgery:
    • Take all proper precautions to minimize intra-operative issues.
  3. After the surgery:
    • Keep a close eye on post-operative recovery
    • Work closely with the patients’ interdisciplinary care team.

If you are considering spine surgery, it is important to sit down with your surgeon and determine how he actively attempts to minimize the risk for failed back surgery syndrome. If you have been diagnosed with FBSS, it is not necessarily the end of the road. There exist many alternative treatment approaches to deal with this syndrome, but once again one size does not fit all. It is important to find a surgeon who has experience in treating patients with FBSS and can offer you multiple treatment options.

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